Provider Demographics
NPI:1205510187
Name:CLARKE, ROSS
Entity type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:CLARKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 N SAINT CLAIR ST STE 1350
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-4795
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:676 N SAINT CLAIR ST STE 1350
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-4795
Practice Address - Country:US
Practice Address - Phone:312-926-4444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-12
Last Update Date:2023-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program